SUBSTANCE MISUSE, VIOL, RISK MANAGEMENT
SUBSTANCE MISUSE, VIOL, RISK MANAGEMENT SW 702
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Developmental Factors of Substance Misuse and Violence Theodore M Godlaski College ofSocial Work University of Kentucky Searching for a Theoretical Framework The question here is Could there be something fundamental in the developmental process of individuals that might make them prone to substance misuse and violence The issue goes below the level of personality but above genetically determined temperament traits Searching for a Theoretical Framework One approach is to develop a phenotypic model A phenotype is the sum ofthe visible properties ofan organism that are produced by the interaction ofthe genotype and the environment It is the product of the interaction between speci c traits temperament and the environment 7 Tartar R StVarlyukuv M lBBE Alcuhullsrn a developmental dlsurder lrl Marlatt o A StVarlderlElus 3 ed Aoololve Behavlurs Washlngtun Dc Amerlcan PsychuluglcalAssuclatlun pp 43767 A Phenotypic Model The following traits have been identified as relating to eventual substance misuse High activity level High emotional reactivity Low sociability Low attention span persistence Low soothability It is not too great a stretch to see that these traits may also relate to increased risk for violence A Phenotypic Model These traits interact with the environment over time to create the behavioral phenotype The quality of interaction is determined by the conjoint characteristics of the individual and the social environment What results is a phenotype that describes an individual prone to substance misuse andor violence mnmental cundm Anusucxal mum ersunahtytrans Amv explra un Abusive Deviant pumshmen peers un Tartar R manwkuv M 198E up 4357 mag threshold pumve armlzl pamsmn A Phenotypic Model The traitenvironment interaction can be very complex when we try to conceptualize an individual with several traits Some attention has been directed to the difficult temperament Negative mood social withdrawal high rigidity high behavioral activity level dysrhythmicity in eating sleep and daily activity and low task orientation A Phenotypic Model Thus various traits interact with any number of environmental factors producing increased potential for substance misuse and aggression The implications The pathways linking temperament to substance misuse and violence are variable The breath of intermediary outcomes produce a population of limitless heterogeneity Another Approach Another way to organize understanding of developmental factors as they affect eventual substance misuse and violence is Attachment eory Attachment Theory is an ethological approach that maintains that our ability to forms attachment to a primary caregiver in earl development influences our later intra and inter personal behavior Model of self dependence Fusmve Negative 1W high pnsmve 1W Model of other avoidance Negauve Fearful high Banhulumew K mu Avmdance ufmllmacy An attachmentperspecuve Jamal afSacml and Permmzl Relananxhxpx 7 1477178 Attachment Theory Attachment can be secure or insecure Insecure attachment can be anxiousambivalent preoccupied or fearful or avoidant dismissing The insecure forms of attachment have been identified with increased likelihood of substance misuse and violence Attachment Theory Unfortunately there has been no study to date that examines both substance misuse and violence in relations to attachment style Interpersonal violence by individuals who have insecure attachment is most likely if their partners are somewhat avoidant in their attachment style Attachment Theory It would seem that at present Attachment Theory offers the best perspective for understanding the developmental factors that contribute to both substance misuse and violence It also allows for an understanding ofthe link between childhood victimization and adult perpetration andor substance misuse Social Learning Theory Theodore M Godlaski College of Social Work University of Kentucky SLT Social Learning Theory has been widely applied to understanding substance misuse lt use in understanding the origins of violence is more recent There is only limited workthat has been done using SLT to understand the relationship between substance misuse and violence Basic Principles Humans are active ratherthan passive agents Predisposing factors may direct the trajectory of social learning but its ultimate outcome is the result of an idiosyncratic process Human behavior is adaptive flexible and situation specific Basic Principles Behavior is volitional and goal directed with outcome and efficacy expectancies figuring largely Maladaptive behaviors are coping strategies rather than pathologies All behavior is subject to the same principles of learning and reflects an interplay between personal environmental and behavioral factors Basic Notions Human being are very good at learning We learn from what we observe We learn from what othertell us We learn not only behaviors but expectations about behaviors Ourfamilies of origin are primary places of behavioral learning We learn most from those with whom we identify Basic Notions Most SLT models are multivariate They are generally backgroundsituational models There are factors that form a general background Exposure to parental substance rnisuseviolence Acceptance ofsubstance useviolence as a solution to specific relational conrlicts Past nistorv ofsubstance rnisuse violence to resolve conrlict There are factors that are situational variables increased stress Expectation tnat suostance useviolence Will relieve stress Expectations tnat substance usevlolerlce Will result in a satisfactory outcorne SLT and Substance Misuse Most applications of SLT focus on substance use as a coping behavior This is accompanied by a deficit in normal social skills The deficit creates increased anxiety around situations requiring that skill There is also a learned outcome expectancy that substance use will relieve the discomfort SLT and Substance Misuse If the outcome expectancy is met than the learning is strongly reinforced This may cause the substance use to continue even when it no longer adequately meets the expected outcome A strong validation for this view comes from the successful use of Social Skills Training in substance misuse treatment SLT and Violence This area is not nearly as well studied It is not unreasonable to assume that violence like substance use may provide a means of coping with specific kinds of distress A social skills deficit similar to that found with substance use may also be at work SLT and Violence Outcome expectancies for the use of violence may be learned in the family of origin This may be the case specifically when the learner and the role model are the same gender and have close identification There is some empirical evidence that this may be the case SLT Substance Misuse and Violence It may be that the two behaviors are learned separately It may be that the substance use provides a rationale for violence It may be that the two interact within the environment in a reciprocal and mutually reinforcing way Risk Assessment Theodore M Godlaski Robert Walker Legal Concerns The law in Kentucky requires reporting of knowledge or reasonable suspicion of child or adult abuse neglect or exploitation Child and adult protective services are obliged to investigate all reports Courts and social service agencies have a variety of methods to assist in the resolution of situations of domestic violence Ethical Considerations Under BeneficenceNonmaleficence the therapist must act in the best interest of the client and do nothing to bring the client to harm Doing nothing to limit risk is never considered preferable to doing something The therapist is obliged to do what is possible to insure the client s safety and that of others Ethical Considerations Under Fidelity the therapist owes the client confidentiality This is a consensual not a natural right When the natural right to live free from the fear of harm is at risk it overrides confidentiality Principal Domains of Victimization Psychological Physical Sexual Stalking All these forms of violence may happen during childhood and adulthood Psychological The most pervasive and damaging form of abuse Denigration lnsults Accusations Humiliation Symbolic violence lntimidation Namecalling Jealousy and controlling Phys1cal Hitting Shoving against wall Slapping Stabbing Choking strangling Punching Shooting Grabbing and twisting arms hands Sexual Rape Sexual abuse as nonconsensual sex Inserting foreign objects into the body Forced anal oral sex Any coerced sexual act Coerced exhibitionism sex acts with others at partner s insistence Stalking Following the partner Calling the partner at work or where partner is expected to be Tapping the phone Contacting others about the partner s presence Checking up on the partner Making unwanted phone calls to the partner at home orwork Consequences of Victimization amp Substance Use increased H eaitn Prubierns increased M entai Health Prubierns increased Substance UseAbuseSubstancer Related problems increased Barriers to Care Substance Use Abuse increased Risky Sexual Eenavmr increased Risk cur Revrctirnizatiun Risk Management as a Duty of Care Clinicians have an obligation to see to the safety of clients Clients may be at risk of self harm Harm to others Harm from others Thus this duty extends to all those who might be at risk from their clients as well Risk Management as a Duty of Care This duty of care falls under the rubric ofdue diligence This duty of care cannot be met by a single risk assessment It extends over time throughout the clinical relationship Consequently the need to be alert to indications that risk is present is always part of the therapeutic relationship A risk assessment is not the work ofthe rst session only Risk Management as a Duty of Care Risk management is not a matter of diagnosis but of behavioral and descriptive assessment Because the circumstances ofthe client are dynamic and ever changing so too the clinician must be aware ofthe effect of these changing circumstances on the risks of victimization and perpetration Risk Management as a Duty of Care Once it is determined that significant risk is present the clinician is obliged to take all reasonable measures to protect the client and others measures may include clear and sustained focus on lethal circumstances increased intensity oftreatment including involuntarytreatment invo vement of external agenc39 Determining such measures should 1respect the clients interest in preserving 39eedom 2 favor the least restrictive effective care 3 recognize the resources available Risk Management as a Duty of Care It is important to rememberthat one kind of risk does not eliminate the possibility of other kinds of risk Individuals who are perpetrators may also be at risk of harm to self Individuals who are victims may also be at risk of harm to self Victims can also be at risk of harming others Techniques of Risk Assessment GlobalClinical ConstructBased Actuarial Actuarially Anchored Structured Clinical Judgement GlobalClinical Risk Prediction 0 Only method until 19805 leading method until 19905 0 Methodology Interview personality testing skill and experience of assessor global judgement of dangerousness o Assessors tend to focus on a few key factors and make judgements simply despite subjective feeling of complex consideration of many factors Approach found to be of little value in predicting violence Identi cation orpersonality characteristics associated with violence Only one such method shown to work the Psychopathy Checklist Revised Hare 1991 mbination of behavioural historical and clinical items related to two factors an antisocial criminal lifestyle and a callous remorse ess use of otherpeople lndividuals identi ed as psychopaths on the PCLR far more likely than nonpsychopathic individuals to commit urtherviolent offences and a a much ras er ra e PCLR revitalized the science of risk assessment but only applies to a small numberof those being assessed Historical information about the person is placed into an actuarial formula related to risk forviolence Several methods available the Violence Risk Assessment Guide the Sex Offender Risk Assessment Guide the Static 99 Methods allow forplacement ofindividuals into risk quot a large normative samp e Methods show good predictive v ty allow for prediction ofspeci c types of violence over a defined time frame Criticized forfocussing on historical elements that cannot change may miss dynamic and crucial risk elements Attempt to address some cr lcisms of strict actuarial approach by allowing for cl 39 information to influence risk judgement Actuarial risk is adjusted up or down from an anchor base on he presence or absence of clinical elements that seem to increase or decrease ris Some inltlal proponents of this approach have abandoned it stat g that actuarial predi t39ons are too good and c nical pre ic ons too poor to risk contaminating the former with the latter Most recent development in risk prediction Attempt to synthesize individual factors known to be empirically related to risk into an evalua ion system ot an actuarial formula no comparisons to normative samples or placement in risk groups Clinician considers and rates all of the known factors and makes ajudgement of risk Approach useful for assessing risk for particular types of violence for whic no enou h normative data is available but in most cases validity not estab hed Rapport Most abuse issues best assessed by female therapists even more so for sexual abuse Abusespecific questions can either be too intrusive OR more likely can be validating If asked by male clinicians may be perceived as an overture They should not be asked too abruptly but must be asked directly using neutral clinical terms Lethality Assessment Risk Assessment Safety Assessment THE FOUR DOMAINS OF RISK Monanan J amp steaaman HJ 2001 Vlolencerlsk assessment A century of research in Frost L E aonnie RJ Eds The evolution of mental health law ipp 155211Washlngton Do Us American chnoiogicaIAssociauon DISPOSITIONAL RISK FACTORS 0 CLINICAL RISK FACTORS HISTORICAL RISK FACTORS CONTEXTUAL RISK FACTORS DISPOSITIONAL FACTORS These are lifelong enduring traits with probable genetic contributions that are associated with increased risk of harm including SUSTAINED ANGRY DISPOSITION PERSISTENT NEGATIVE HOSTILE INFERENCES SUSTAINED HOSTILE ATTITUDE PERSISTENT INFERENCE OF BEING INJURED HARMED BY OTHERS DISPOSITIONAL FACTORS HYPOAROUSABILITY The under inhibited temperamental type HYPERAROUSABILITY The overly inhibited temperamental type LIMITED INTELLECTUAL OR COGNITIVE ABILITY DISPOSITIONAL FACTORS IMPULSIVITY Cognitive impulsivity ie jumping to conclusions hasty inferences Behavioral impulsivity 39 THRILL SEEKING 39 A39I39I39ENTIONAL DEFICITS CLINICAL FACTORS CONDITIONS THAT CONTRIBUTE TO HEIGHTENED RISK Command hallucinations particularly when content is threatening harm Severely compromised sensorium Hallucinations secondary to withdrawal or intoxication Highly suspicious attitude or thinking Poor adherence to prescribed medications CLINICAL FACTORS Acquired brain injury Delusions Alcohol cocaine amphetamine hallucinogen inhalant use marijuana only as it impedes psychotropic medications and contributes to social skill deterioration CLINICAL FACTORS 39 Severely depressed mood particularly agitated depression PTSD Panic Antisocial personality traits the greater the number of these the higher the risk profile Borderline traits HISTORICAL FACTORS Events in the person s history that are associated with heightened risk of harm including Childhood victim experiences of sexual abuse particularly when accompanied by threats Childhood victim experiences of physical abuse or witnessing violence toward other family members or parents HISTORICAL FACTORS Severe and persistent neglect in childhood Attachment disorders Early onset of aggression pre adolescent This does not necessarily include all conduct disorder traits but refers to higher levels of aggressive behaviorthat causes injury and is persis ent not reactive to abuse incidents HISTORICAL FACTORS Suicide attempts and family history of suicide completion Adult victim experiences of physical andor sexual violence Childhood placements in foster care or institutions the greater the number the higher the risk profile CONTEXTUAL FACTORS Circumstances and situations that aggravate risk and that can potentiate dispositional clinical and historical factors including Loss or threatened loss of residential setting Loss of loved one caregiver or significant relationship Loss of income job or financial benefits CONTEXTUAL FACTORS Living in unmarried relationship Presence and availability of handguns Availability of lethal amounts of medication Serious legal problems Living with or in relationship with violent partner Adult males living with nonbiologically related children Environmental exposure to heavy substance RISK LEVELS 0 LOW RISK MODERATE RISK 0 HIGH RISK CRITICAL RISK There are no no risk individuals LOW AND MODERATE RISK STATUS LOW RISK status may be assigned to those who few if any identifiable risk factors or predisposing factors or arm an no expressed intent to harm self or others 7 Low risk cases can for occasional risk scanning to 39ne changes in situation or status but NO definitive ortargeted risk managemen actions MODERATE RISK status is assigned to those who do not have significant risk factors but who have expressed threats to harm self or others Situational contextual factors are very important in these cases Cl cal responses should be shaped by the nature of the expressed risk and risk should be monitored nearly every session HIGH AND CRITICAL RISK STATUS HIGH RISK status should be assigned to those who independent of immediate threats to harm self or others have significant risk factors that predispose toward danger These individuals should be monitored closely every session and treatment should be aimed at harm reductionprevention HIGH AND CRITICAL RISK STATUS CRITICAL RISK status should be assigned to those who have significant risk factors AND are expressin verbally or behaviorally intent to harm self or others They combine high levels of predisposing factors plus situations and intent to harm The clinical response must be aimed at harm reduction and vigilant care to protect self andor others RISK SCANNING RE Self harm Have you thought of harming yourself How would you do this Have you given thought to suicide in the past Are you thinking of it now RISK SCANNING Harm to others Have there been times in the past when you have injured others How so Have you found yourself thinking about harming others In what ways Do you find yourself losing your temper easily What happens when you do this RISK SCANNING Harm to self from others Do you ever find yourself fearing injury or harm from someone w so What do you think would explain this Is anyone threatening to harm you Have you been seriously injured by anyone before How so Do you feel unsafe in your home In what way RISK SCANNING If the individual answers in the affirmative to any of these items and the immediate followup questions elicit positive answers then the clinician should go ahead and conduct a full risk assessment RISK SCANNING If the individual answers these items negatively and does not fall into any of the high risk groups then the scan should suffice This individual would fit into the low risk category described above The clinician should remain vigilant for the appearance of risk factors at any time in therapy and should revisit this scan from time to time in treatment Risk Assessment Perpetrators DISPOSITIONAL CHARACTERISTICS Look For BASIC DISPOSITIONAL CHARACTERISTICS Imales are far more likely to batter threaten or coerce spousal perm rs Imales with early age onset of alcohol use and whose fathers were alcoholic have higher risk of aggression 39 an angry hostile disposition is a signi cant marker arm to others an no self there are three variations there are at least three types of hatterers in the literature Risk Assessment Perpetrators DISPOSITIONAL CHARACTERISTICS emotionally reactive up hostiledepressive 0 poor inhibition of impulses poor social skills has an explosive Volatile quality 0 experiences a feeling of loss of control when gry is highly aroused by an tates impresses others as being immature and often ineffectual Risk Assessment Perpetrators DISPOSITIONAL CHARACTERISTICS instrumental m perfec or stiqover controlling 0 is Very controlling experiences calming effects from Violence an anger episodes opposite to the reactive type is extremely suspidous andjealous 0 is emotionally constricted has rigid controlling personality style Risk Assessment Perpetrators DISPOSITIONAL CHARACTERISTICS antisocial gym antisocial is not attached to others 7 Very likely to abuse drugs or alcohol 7 has poor impulse control 7 blames others for negative outcomes 7 little or no remorse fuses Violence to get his way rather than to control others Risk Assessment Perpetrators DISPOSITIONAL CHARACTERISTICS 0 risk taking temperamental traits particularly when assoin39ated with temperament of hypoarousability the trait of needing high thresholds of excitement in order to achieve desired mental state 0 poorly regulated emotions poor ability to inhibit impulses attentional de cit 0 poor ability to put ideas and feelings into words hyperactivity Risk Assessment Perpetrators Clinical Features Clinical Features use of bstances use not necessarily abuse or dependence is a factor 0 cocaine amphetamine including MDMA post intoxication and alcohol are most often associated with Violence and harm to o ers alcohol use may be associated with the degree of injury or harm caused by the aggressive act It is a potentiator but not a cause of Violence Risk Assessment Perpetrators Clinical Features acquired brain injury 0 affec w instability and extreme mood variations 0 in batterers meme controlling behaviors jealousy and suspicious attitudes toward armexs P 0 beliefs about the legitimacy of male dominance and rigid stereotypes about male rol fatalistic beliefs Risk Assessment Perpetrators Clinical Features 7 poor self esteem and most importantly low self cacy the belief that one is actu able to affect change in his or her life 7 personality disorder particularly the B Cluster disor ers I Primarily Antisocial and Borderline secondarily Narcissistic 7 bipolar disorder 7 presence of suiridal thinking Risk Assessment Perpetrators Clinical Features B Cluster Antisocial Conformity to law lacking Obligations ignored Reckless disregard for safety Remorse lacking Underhanded lies and cons Planning insufficient impulsive Temper irritable aggressive Risk Assessment Perpetrators Clinical Features B Cluster Borderline Abandonmentfear of Mood instability Suicidal selfmutilating behavior Unstable intense relationships Impulsive 2 potentially damaging areas Control of anger lacking Identity disturbance Dissociative symptoms transient and stress related Emptiness chronic feelings of Risk Assessment Perpetrators Clinical Features B Cluster Narcissistic Personality Disorder Special believes heshe is Preoccupied with fantasies Entitlement Conceited grandiose and selfimportant Interpersonal exploitation Arrogant haughty Lacks empathy Risk Assessment Perpetrators Life H isto ry Life History 7 childhood alperience of physical samal and emotional a use 7 childhood witness to domestic violence 7 early history of aggression and bullying 7 early history of sexual aggression or adultlike uits 7 poor adaptations to social norms in school and in personal relationships Risk Assessment Perpetrators Life H isto ry 7 early arperience with alcohol inhalants tobacco and other drugs 7 history of con icts and instability in personal relationships that lead to physical harm to self or others adolscent experiences with ate violence 7 history of sexual promiscuity and HIV high risk samal activity Risk Assessment Perpetrators Life H isto ry 7 history of suicidal attempts or gestures the greater the number of attempts the greater the risk both for suidde and uxotiu39de 7 adult arperiences of violent crime rape or brutality can include witnessing AND being a victim Risk Assessment Perpetrators Context and Environment Context and Environment 7 partner s decision or action to separate or 39vurce 7 belief that spouse or partner is involved with another person 7 ready availability of guns particularly handguns 7 loss of employment and or signi cant economic hardship Risk Assessment Perpetrators Context and Environment 7 incidents of perceived injury to self esteem 7 partner has children from an earlier relationship living in the family 7 partner is enjoying greater success in work or other social settin s 7 individual s socialization is predominantly in maleonly settings OR the individual is socially isolated 20 Risk Assessment Perpetrators Mitigating Factors Mitigating Factors 7 desire to avoid negative consequences such as arrest protective order or incarceration 7 belief that there will be legal or other serious consequences for violence toward partner or children 7 willingness to participate in banerers treatment rogtams AND any olher treatment that might be indicated medication or other therapy eg subslance abuse treatment Risk Assessment Perpetrators Mitigating Factors 7 empathy for others realistic guilt for harmful actions including harm to the children in the family who witness the violence 7 history of periods of alcohol and drug abstinence 7 belief that violence to self or others is wrong 7 childhood or other experiences that instill a conviction against violence to self or others What to Ask When you become angry do you ever have thoughts of hurting yourself I What kind of event is MOST likely to make you feel suicidal When you feel suicidal what are you thinking about your rtner Do you ever find yourself Wanting to die How would you harm yourself How would you put the plan in place 7 step by step What weapons do you have access to What about drugs or other means of self harm 21 What to Ask I Where would your family or partner be at the time of your harming yoursel W en you have attempted suicide in the past how have you done it I What has happened in the past to keep you from killing yourself I What has made the hopelessness go awa I How much more likely is that you will try to hurt yourself when you are high or drunk I When you want to harm yourself are you more likely to want to harm others as well What to Ask I In what way do you take control when angry at your partner What are the steps by which you insure that you are not going to be put down When you think about getting back at your partner how do you do it When you have been angry how have you dealt with it in the past Have you gotten back at your partner in the past How do you follow through on threats What to Ask Whatwa the earliest time in your life diatyou wete involved in a ght Thmtlned othzn with a weapon u as Whatwl the hm hm yuu used fame with it girl friend or date when she was not acn39ng e wayyw ihaught she should t the pun Do you plan these things out in yuur mind 5139 do they just quothlppen out of the blue If they just happen what has helped you to remain them in the past 22 What to Do Explore the vion39m s experience ufthe offender Ind her assement afintent degree of harm history ofevems and saquen Ekplme die vidim s plan for her own safety and take steps to link her with services that can assist this including 7 main unpomn Dss pawnth leimblu law 7 lxucut um dua inwum ifumnl Ipod c shrinks m pusn 7 ms refurll in lawmammmwhm uvm m 7 maintain Upln line of eurnrmnimh39on lawnn victim and 7 lduiuu mdn39ufnmu39vfurrrHngrlpomlndfurhpine oran mam bahInn public agendas eollmnml pm and othuswlun dun ssth is pa What to Do 7 If the individual is making threats of actual specific harm execute duties to warn and to protect by contacting the Victim and law enforcement agency nearest the Victim 7 Do not rely on any form of treatment as the sole means of reducing risk of harm or protection for the Victim 7 treatment settings may be considered IN ADDITION to law enforcement or other safety referrals for the Victim 7 When the individual discloses acts of domestic Violence set aside traditional mental health or substance abuse counseling and shift focus to risk reduction What to Do Where there is high or critical risk AND evidence of serious mental disorder bipolar disorder delusional disorder schizophrenia consider hospitalization and execute duties to warnprotect If the high risk is associated with alcohol intoxication refer for detoxi cation AND execute duties to warnprotect 23 What to Do With evidence of domestic violence risk discontinue any mari or 39 y coun 39 until the violence is suf ciently dormant for safety to be reasonably predictable for the victim and other family members 0 Be arceedingly cautious about the use of individual therapy with individuals who present with domestic violence but no other severe mental disorder Risk Assessment Victims Dispositional Characteristics Dispositional Characteristics 7 a shy personal style or a temperament that is characterized by hyperarousability may be associated with increased risk of harm from others 7 alternatively risk ta ng temperamental traits d a combative reaction to assault can be associated with increased risk harm Risk Assessment Victims Clinical Features Clinical Features 7 use or substances use not necessarily abuse or dependence 15 a factor 7 eoearne arnpnetarnrne including MDMA and alcohol are rnost assoeated wrtn rnereased nsk of harm 7 alcohol and Eenzodiazepme use assoerated with rrnparred abruty to sound Judgments about safety and to take steps to avoid arrn 7 alcohol and other CNS depressants are assoerated with surerde and selfrmuulation in those with severe sexual andor pnysreai abuse in o aten for nernreaidrssoerauonquot e narcotic analgesic use ean resultm danger due to its illegality and exposure to antisocial lifestyle more than pharmacological factors Risk Assessment Victims Clinical Features Clinical Features ability make herself and children and it is associate diminished ability to be a reliable witness with law I rr 7 depression 7 beliefs about the legitimacy of male dominance an ri 39d stereo s about male roles rigid religious beliefs about marital obligations and the roles of women Risk Assessment Victims Clinical F eatu res Clinical Features 7 poor self esteem and most importantly low 5 cacy the belief that one is actually able to affect change in his or her life lack of belief in a better future 7 personality disorder particularly the B Cluster disorders 7 bipolar disorder 7 presence of suiridal thinking Risk Assessment Victims Life History Life History 7 childhood aperience of being a victim of physical sexual and emotional abuse particularly sexual abuse 7 childhood witness to domestic violence 7 poor adaptations to social norms in school and in personal relationships experience with alcohol inhalants tobacco and other drugs 25 Risk Assessment Victims Life History Life History 7 history of con icts and instability in personal relationships that lead to physical harm to self or others adolescent experiences with date Violence 7 history of suicidal attempts or gestures the greater the number of attempts the greater the risk 7 adult Victim experiences of Violent crime rape or brutality can include witnessing AND being a Victim Risk Assessment Victims Context and Environment Context and Environment 7 a decision or action to separate or seek a 39vor m a battering partner 7 Pregnancy 7 having young dependent children 7 ready availability of guns in the home parti arly 7 partner s loss of employment and or signi cant economic hardship in the family Risk Assessment Victims Context and Environment Context and Environment victim has children from her earlier relationship living in the family 7 victim s partner perceives her family of origin as adversarial 7 social isolation including geographical isolation 7 victim is enjoying greater success than partner in work or other social settings 7 victim is isolated by partner and has limited freedom of access to goods and services 26 Risk Assessment Victims Mitigating Factors Mitigating Factors 7 desire to seek safety and work toward a safety plan 7 belief that there will be legal or other serious consequence for violence toward self or children 7 willingnas to use treatment and social services 7 availability of shelter servic Risk Assessment Victims Mitigating Factors Mitigating Factors 7 availability of advocacy services 7 ability to reduce drug or alcohol use 7 availability of effective law enforcement personnel and polid 7 availability of supportive family and friends What to Ask 7 Do you have thoughts of hurting yourself 7 What situation is MOST likely to make you feel suiddal 7 Do you ever nd yourselfwanting to die 7 How would you harm yourself 7 How would you put the plan in place step by step 27 What to Ask 7 Where would your family be at the time of your banning yourself how would you protect your children 7 When you have attempted suidde in the past how have you done it 7 What has happened in the past to keep you from killing yourself 7 What has made the hopelessness go away 7 How much more likely is that you will tryto hurt yourself when you are high or drunk What to Ask 7 How have you been injured by others including your partner in the past 7 Are you in danger now How so 7 What is the history of events and how violence erupts 7 Have threats been made against you your children or other family members recently What to Ask 7 Are you in danger of being harmed physically Sexually Emotionally 7 Has anyone been a witness to the threats or the assault 7 Where are you most threatened At home At work 7 Have you been more likely to be harmed when on drugs or alcohol How so 28 What to Ask 7 What plan do you have for your safety 7 What has protected you in the past 7 Is there anything about the present situation that maka it different from the past What to Do 7 Begin safety planning with the victim and children 7 Make referrals to shelters victim advocates and to law enforcement where in quotm d 7 Rehearse safety plans with victim 7 dress treatment needs along with safety planning but do not use treatment as an alliemalive to safety planning 7 If the individual is intcated and in need of shelter cpnsider detoxi cation program crisi 7 Link the individual with a victim s advomte in the 10121 are What to Do 7 Look closely at the individual39s level of impulsivity and her history of acting on impulses during cri intoxicated slates 7 Pay special attention to the availability of the means for suicide 7 When suicidality has been identi ed the clinician should 1 plate enhnnned safety arrangernt for die individual 2 engage die individual in a no harm agreement unn39l treatment an me nd m39sis managemenl and 39 3 be available so the individual far manning crisis 29 What to Do 7 Do active telephone followup on missed appointments if the individual has told the dinidan that this is safe and will not provoke harm from the offender 7 Continue to monitor suicidal thoughts from session to sssion 7 At any point in the interview seek consultation when in doubt about the degree of lethality of the individual s response and the appropriate risk management actions Lethality Assessment Based on the work of Jacquelyn C Campbell Ph D RN at Johns Hopkins Campbell JC Webster D et al 2003 Risk factors for femicide in abuse relationships Results from a multisite case control study American Journal of Public Health 93 7 10891097 11 city case control study Femicide cases n31 1 Attempted femicide cases n1 Abused controls n427 Non abused controls n418 Danger Assessment Items Comparing ActualAttempted Femicide n493 and Abused past 24 months Controls n427 plt05 ActualAttempted Cuntrcii Gun iri HDUSE 64 ie 62 i8 Partnerthreatenedtu mi Vlc m 57 i4 Physicalviulence increased infrequericy 56 24 raiiii i u Wing 55 53 Victim believes partneris capable cit Killing 54 24 her Partnermestu EHDKE Viith 5u iu Partnerfurced Vl lm tci have sex 39 i2 Stalking scciic 4 e 2 4 30 Victim vs rerpeuatur ownership of Gun in Femicide n311 Attempted Femicide n182 Abused Controls n427 and NonAbused Controls n418 Vlcllm Pelpellalov Significant plt05 Variables Before Incident overall t 85 Significant plt05 Variables at Incident Level 31 Danger Assessment Instrument Jackie almpbell Using the calendar please rnark the apdproxnnate uates uunn the pastyear when you were beaten by your husban urpanner Wnte unt atuate how bad the incident was according to the following scale 1 Slapping pushingnolmune5andoriasllrl 2 Punching kicking bruises outs andoroontlnulng pall l 3 Beating up severe oontuslons burns broken miscarriage A Threat to use weapon neao inlury internal inlury oennanent inlury miscarriage 5 Use of weapon wounds from weapon lfany oflhe descriptions forlhe nlgner numberapply use the highernumber ark Yes or No for each of the following quotHequot refers to your husband band ex er orw oever is currently physically hurting you 1 Has the physical violence increased in severity or frequency over the past year 2 Does he own a gun 3 Have you left him after living together during the past yean 3 If have neverlived with him check here 4 is he unemployed 5 Has he ever used a weapon againstyou or threatened you with a lethal weapon 5a If yes was the weapon a gun 6 Does he threaten to kill you Has he avoi ed being arrested for domestic violence a Do you have a child that is not his 9 Has he everforced you to have sex when you did not wish to do so 10 oes he evertry to cho eyou 11 Does he use illegal drugs Ev drugs I mea amphetamines speed angel dust cocaine quotuppersquot or rackquot street drugs or mix ures 12 Is he an alcoholic orproblem drinker 13 Does he control most or all of your daily activities For instance does hetell you who you can be friends with when you can see your family how much money you can use o when you can take the ca lfhe tries but you do not let him check here 14 is he violently and constantly jealous ofyou For instance does he say quotIf I can t have ou no one canquot 15 Have you ever been beaten by him while you were pregnant If you have never been pregnant by him check here sllashe ver e r toco m39 su 39 13 Do you believe he is capable of killing you 19 Does he follow or spy on you leave threatening notes or messages on answering machine destroy your property or call you when you don39twant him to 20 Have you ever threatened ortried to commit suicide Total Yes Answers Fro m munMWAangerassessm entorgWebApplicationl pagesdaDAEnglishp 32 Overall Treatment Model for Women with Victimization Attention to immediate detoxification as risk factor for reabuse Assess whether the abuse is current or by history if current go to the next two steps immediately Consider shelter alternatives Develop first stage safety plan will be elaborated later in treatment 33 Substance Abuse and Violence SW 702 Theodore M Godlaskl Two Minute Paper Take two minutes to consider the following question and write write down as much of an answer as you can manage If you wanted to study the relationship between violence and substance use where would you go to look for data Pair up with a fellow classmate share your answers and come up with a combined statement Some interesting statistics In 1997 slightly in excess of 3 million reports of child abuse were received by social service agencies in the US In the US in 1997 over 1000 children died as a result of abuse Based on a nationally representative survey in 1998 there were 1 million violent crimes committed against women by their partners Some interesting statistics Results from the 1999 Household Survey indicate that 103 million Americans 12 years of age and older were dependent on alcohol or other drugs or both Reliable estimates indicate that one in four children experience parental substance abuse or dependence and one in ten live with at least one parent who is misusing alcohol or other drugs Eslrmtm lurkIS an Ihanm S mcmmm Ma 11 Hr Vnurlju mm wnlh one nr Whm mans wnh pas er Suh ance Aim at u nqmdmuz znn1 Sam A we m M w lllizil m ng quotv m Eslmim lurkIs m IhanmdS and pecan195 Anna bumtad 9mm swim rm mm quotmm s I may tinVnwnndll TEL Youw mm s I am mu 1 Pmmtages mrmms and Mums thng unhomnrwhmchllrtmngm m 5 N m 11 u mum liqmm pas er uhsanmnhmmnqanmuz mm m m H m mm mm m a Getting a clear picture of the overlap between these two serious problems can be difficult There is a disparity between how different studies define relationship violence and substance use problems Underestimate can occur because of small sample size bias in sample selection underreporting by subjects and by official reports Getting a clear picture ofthe overlap between these two serious problems can be difficult Conversely other factors may act to inflate estimates of the overlap Because official reports are often related to legal action there may be a tendency to overemphasis the presence of substance use and relationship violence either to enhance prosecution orto present mitigating circumstances Child Abuse physical or mental injury sexual abuse or exploitation or maltreatment of a child under the age of 18 by a person who is responsible for the child s welfare Child Abuse Prevention and Treatment Act 1984 Parental substance use in itself does not constitute child abuse or neglect However substance use may lead to the parents disappearance for hours or days at a time substance related reduced emotional and physical availability and reduced cognitive capacity Further substance use may lead to exposure of children to illegal behavior and to dangerous persons Data from Child Protective Senices Reports Data from Child Protective Services reports is a valuable source of information but is bias due to much greater likelihood of reports being made of families whose income is low In 1998 the national rate ofmaltreatment was 15 per 1000 children Data from Child Protective Senices Reports 7 Neglect ls tne most prevalent form of maltreatment 52 arld tne leaolng cause of removal ofchlldrerl from parental substance abuslng nomes Women are most ofterl accused of neglect e thslcal abuse 23 sexual abuse l4ano emotlonal abuse 6 slmllar proportlon ofmales arld females are perpetrators arld victims ofphvslcal arld emotlonal abuse males are tne predomlrlarlt perpetrators of sexual abuse 82 arld females tne predomlrlarltvlctlrns 77 Data from Child Protective Senices Reports In 1994 substance abuse figured in 81 of cases of child maltreatment reported to CPS agencies in the US it was deemed the primary cause in 40 of cases The problem is complex Empirical Studies Famularo et al 1986 found that in a random sample of families involved in court cases related to child maltreatment 52 had one or both parents who had a present or past diagnosis of alcohol dependence as compared with 12 of normal controls Famularu R StuneK Elar umR StWart R lBEEJAlcuhulism and severe child maltreatment American Journal ofOrtnopsycnialry 5B 4817 485 Empirical Studies Shah et all 1995 in a study ofchild sexual abuse cases found that 75 ofperpetrators had evidence of substance use pro ems Famularo et al 1992 showed a strong association between parental alcohol abuse and physical abuse of children and a strong link between cocaine abuse and sexual abuse of children Shah RZ Dall PW amp HelnrlEhs T l995 Familial influences upuri the DEEunenEe CW Ehlldhuud sexual abuse mumsof Child SawsAbuse 4 456i Famulam R Kinschen f R amp Fentun T l992 Parental substance abuse and the nature ofchildmarrealment Child Abuse and Neglect l6 4754183 Epidemiological Studies maltreatment Adults with an alco o o disorderwere 27 times more likely to have physically abused a child and 42 times more likely to have neglected a child than individuals without substance related problems Kelleher K Cha ih M Hullehbergl StFischer E l994 Alcuhul and drug disurders amuhg physically abusive and neglectful parents m a cummuhity based sample American Journal ofPubic Health 84l r lEBEI Substance abuse is a strong predictor of child h rdrug Please Note It is important to rememberthat none of this research indicates a causal link between substance use problems and child maltreatment Correlation indicates some kind of interaction but correlation is not causation Two Minute Paper Take two minutes to consider the following question and write write down as much of an answer as you can manage What are the cultural factors in Kentucky that may contribute to intimate violence Pair up with a fellow classmate share your answers and come up with a combined statement Linkage of Child Abuse and Adult Substance Abuse Chandy et al 1996 in a large study of adolescents in grades 7 through 12 found that females who endorsed sexual abuse items also more often reported weekly use of alcohol and marijuana than randomly selected females who did not endorse sexual abuse items Chandyd M Elum R W amp Resnlck M D 1996 Female adulescence with a histury Bf sexual abuse Joumalof interpersonal llDenLE 11503518 In the same study researchers confirmed that males who endorsed sexual abuse items reported greater substance use before and during school more frequent alcohol and marijuana use and more frequent binge drinking than females endorsing sexual abuse items Chand J M Ellum RW SkRESnlEk M D lBBB Genderspecific uutcumes fur sexually abused adulescents Child Abuse and Neglect ZEI lZlBrlZSl The literature generally confirms an elevated risk of substance abuse or dependence among adult survivors of child abuse as compared with non victims Largelard vv amp Harlogers l998 Child sexual and physical abuse and alcoholism A review JoumaofSludesin Acohol 59 3367348 Millei B A Ma Llll l E y amp Downs W R l997 Alcohol drugs and violence in children s lives ln M Galanter Ed Recent developments in alcoholism ol l3 Alcohoand lioence pp 3577385 New York Plenum McCauley et al 1997 in a sample of female patients seen in primary care clinics found that women who reported a history of victimization priorto age 18 were more likely have a current history of drug use and alcohol related problems than women reporting no history of victimization i E Dill L Schrueder AF DeChant HK Ryden J Derugatis L R i i Elass E El lBB7 Clinical characteristics ufvvumen With a histury uf child abuse JAM4127 lSEZrlSEE Polunsy and Follette 1995 reviewing the literature note that in psychiatric samples alcohol and drug problems are more frequent among survivors of childhood abuse 27 37 for alcohol 21 51 for drugs in comparison to non victims 4 20 for alcohol 2 27 for drugs F39ulusrly M A StFullette v M labs Lungrterm eorrelates or ehild sexual abuse Theury ahd rElevv or the erhpirieal literature Applied amp Prevenllle Psychology 4 1434 BB ln addiction samples rates of selfidentified childhood sexual victimization are significantly higherthan in the general population 4975 for women and 12 for Studies of alcoholic populations indicates that histories of childhood neglect and physical abuse are equivalent for men and women sexual abuse is 4 times more prevalent among women than men but Local Data In a gender speci c treatment program for rural substance misusing women in Kentucky n126 e 37 3 reported no history oryictirhizatiori 7 l4 3 reported history of physical abuse only 7 ll l reported history of sexual abuse oril e 37 3 reported history of both physical and sexual abuse 7 Women With history positiye ioryictirhizatiori had signi cantly plt 05 higher scores for curreri anxiety and global severity and reported being significantly more troubled by theirerhotiorial symptoms a 9 Q SpousetoSpouse Physical Abuse Analysis ofnational crime data 39om 1992 through 1995 indicates that 66 ofall victims of intimate violence repo e t at offen ers ha een drinking This gure increased to 75 forvictims ofspousal vio en ce This compares with about 31 of victims of stranger violence reporting that offenders were drinkin Greenfield LA 1998 Alth and crime An analysis anemonedata on preysems ofalcoholinvolvemenlin crime Wasningtun Dc US Department er JuS EE Bureau Elf Justice Statistics Alcohol intoxication on the part of the perpetrator is positively associated with the victim s risk of serious injury It is interesting to note that the victim s wife s intoxication is generally unrelated to the frequency or severity of abuse However the absence of either alcohol and drug intoxication in many episodes ofspousal violence indicates that intoxication is neither necessary nor suf cient for wife assault to ensue LEEW V ampWeinstein S P 1997 HEIW far have WE Emma A critical rElEW Elf researen on men whu batter in M GalamerEu Recent ueveiuprnents lfl alcoholism Vul 13 Ammoand Violencepp 3377356 NEW Vurk Pl num Recent Data William FalsStewart followed 137 men entering domestic violence treatment and 135 men domestically violent men entering alcoholism treatment over15 months Odds of any maletofemale physical aggression were 8 times higher on drinking than nondrinking days and chances ofsevere aggression were 11 times higher FalsStwa W m3 The eccunence utpannev physical aeevessmn an days an alcohol cunsumptmn Alunetumnaiman s1udy JuumalmCunsumngandCuunselmg minimum 71 1 61752 Compared to nodrinking days the odds of maleto female physical aggression on days of heavy drinking 6 drinks24 hours were more than 18 times higher and the odds of severe aggression were 19 times higher Individuals seeking treatment for domestic violence who have more severe alcohol misuse problems were found generally more likely to engage in partner violence on an given day regardless of drinking than their counterparts without drinking problemsquot p 0 Two Minute Paper Take two minutes to considerthe following question and write write down as much ofan answer as you can manage What are the cultural factors in Kentucky that may contribute to problematic use of alcohol andor other u squot Pair up with a fellow classmate share your answers and come up with a combined statemen Possible Interaction Effects of PmDm9Emmmemvmm Independent Effect Rationalizing Effect Causative Effect Additive Effect Synergistic Effect Neutralizing Effect Contextual Effect General Considerations about Substance Misuse and Family Violence Theodore M Godlaski College ofSocial Work University of Kentucky General Considerations about Substance Misuse and Family Violence In reviewing the data about the coincidence of substance misuse and partner violence and child maltreatment we ask Is there anything about the occurrence of substance misuse and domestic violence throughout the life cycle that might help us better understand the linkage between the two Development Issues in Alcohol Use In general heavy alcohol use is highest in the age group 1822 years and decreases as individuals reach 30 years This is true both for men and women This is consistent with McClelland s early findings related to maturing out of heroin users It is interesting to note that not everyone matures out 38 of men and 15 of women are still doing some heavy drinking at 30 Development Issues in Intimate Partner Violence Intimate partner violence seems to follow a developmental trajectory similar to substance use Younger couples who have been married a shorter time experience more spousal aggressnon Over time as the couples age aggression becomes less prevalent Development Issues in Intimate Partner Violence Inn vinlence I intermimnt vinlznce i cnnsimnt vinlznce o Lary K DEar1mglelal 198 Prevalence and Stability urphymi aggessiun belwem wuuses Alugmdmal study qumal quhmml and Cunsulunngychnlugy 52637268 Development Issues in Intimate Partner Violence Some general findings prartner violence is going to occur in a marriage it will most likely occur early otten before marriage There is a relatively small number ofindividuals who are consistently violent more o en violence seems to be sporadic Individuals who are consistently violent tend to also be more severely violent Not surprisingly marital satisfaction is inversely ce related to incidents ofpartner vrolen Development Issues in Child Abuse Although it would be reasonable to assume that younger parents might be more likely to abuse their children due to lack of social and coping skills and the combination of maturational stresses as well as parental stress However there is little empirical evidence that this is the case Alcohol Effects in Marital Violence Although there is clearly a connection as we have already seen it appears to be mediated by a number of factors marital dissatisfaction alcohol belief that intoxication excuses bad behavior alcohol power fantasies alcohol belief in superiority alcohol Alcohol Effects in Child Maltreatment There is general agreement among studies that substance misuse is linked to increased probability of child maltreatment This link seems especially strong in relation to acute intoxication and child neglect However the role of substance misuse in child physical and sexual abuse is much less clear Alcohol Effects in Child Maltreatment Maternal substance misuse seems to markedly increase the probability of child sexual abuse by individuals both within and outside the family Maternal substance misuse and antisocial characteristics seems linked to increased likelihood of child physical and sexual abuse Alcohol Effects in Child Maltreatment Moderating factors that might link parental substance use to child maltreatment have been almost completely neglected This may be partly due to unwarranted assumptions being made aboutthe connec ion Substance abuse is riot causal but only an excuse forylolerlt behaylor Substance use Slmply disinnents antisocial tendencies There is a complete absence ofany theoretical underpinning for models that link parental substance e and child maltreatmen Substance Abuse and CoOccurring Psychiatric Disorders in Victims Theodore M Godlaski College ofSocial Work University of Kentucky Two Minute Paper Take one ortwo minutes to think and jot down an answer to the following question What kinds of emotional or psychiatric problems would you expect to find in the victims of child sexual abuse Discuss your thoughts with a partner and be ready to share them with the class Theoretical Perspectives There are a series of theoretical perspectives that all stem from understanding PTSD as an outgrowth of victimization All ofthese perspectives link depression substance use and victimization through the mediation of PTSD Self Medication Stewart et al posit a selfmedication model to link victimization substance misuse and depression Traumatic abuse precipitates PTSD PTSD symptoms include depressionanxiety Substance misuse is an attempt to dampen PTSD symptoms PTSD The person has been exposed to a traumatic event in which both of the following were present The person experienced witnessed or was con 39onted with an event or events that involved actual orthreatened deat or serious injury or a threat to the physical integrity of self or others The pe on s response involved intense fear helplessness or horror An Aside John Briere USC raises some interesting oints The DSMIV TR de nition oftrauma does not include the fact or threat of harm for psychological integrity It does not allow for the numbing that frequently accompanies and followst auma ic experience It allows for hearing about harm an unlikely source of traumatic experience The response described is easierto meet in women than in men and is unlikely in emergency responders of either gender An Aside Trauma might be better defined as a high intensity adverse event that exceeds the individuals existing resources for coping and response This definition recognizes that it is not the event but the subjective reaction to the event and the subsequent ability to deal with it that is the defining feature PTSD The traumatic event is reexperienced in one or more of the following ways Recurrent and intrusive distressing recollections of event39 Recurrent distressing dreams of the event Acting or feeling as ifthe traumatic event were reoccurring Intense psychological distress at exposure to external or internal cues39 Psychological reactivity on exposure to external or internal cues PTSD Persistent avoidance of stimuli associated with the trau a and numbing ofgeneral responsiveness as indicated by three or more ofthe following 7 Efforts to avoid thoughts feell gs orcohversatioh associated With the trauma to avoid activities places and people that arouse recollection of the trauma 7 inability to recall important aspects ofthe trauma 7 Mafkedly diminished interest in participation in sigmficaht activities 7 Feelings of detachmeht or estrahgemeht from others Restricted rahge ofaffect 7 Sense of foreshortehed future PTSD Persistent symptoms of increased arousal as indicated by two or more of the following Dif culty falling asleep or staying asleep Irritability or outbursts ofanger i iculty concentrating Hyper vigilance Exaggerated startle response Duration of more than 1 month The disturbance causes clinically significant impairment or distress in social occupational or other areas of function Acute Stress Disorder The person has been exposed to a traumatic event in which both ofthe following were present e erson experienced witnessed or was confronted with an event or events that involved actual orthreatened death or serious injury or a threat to the physical integrity of self or others The per n s response involved intense fear helplessness or horror Acute Stress Disorder Eitherwhile or after experiencing the distressing event the individual has 3 or more of the following dissociative symptoms Sense of numbing detach ment or absence of emotional responsivene 39 ss Reduction of awareness ofsurroundings Derealization Depersonalization Dissociative amnesia Acute Stress Disorder The traumatic event is reexperienced in at least one of the followin wa s Recurrent and intrusive distressing recollections of the event Recurrent distressing dreams ofthe event Acting or feeling as if the traumatic event were reoccurring39 Intense psychological distress at exposure to external or internal cues Psychological reactivity on exposure to external or internal cues Acute Stress Disorder Marked avoidance of stimuli that arouse recollection of the trauma Marked symptoms of anxiety or increased arousal The disturbance causes clinically significant distress or impairment or impairs individual39s ability some necessary task such as obtaining help or mobilizing personal resources by telling family members about the traumatic experience Acute Stress Disorder The disturbance lasts for gt 2 days and lt 4 weeks and begins within 4 weeks of the traumatic event The disturbance is not due to the direct effect of substance use or a general medical condition is not better accounted for by a brief psychotic disorder and is not merely a worsening of an already existing Axis I or II disorder Interesting Insights from John Briere Trauma can be impersonal or interpersonal Whetherit is one or the other has a good deal to do with the victims perception Interpersonal trauma is much more likely to result in symptoms In adults rape and torture and in children sexual abuse are most likely to produce severe symptoms The earlier in development that trauma occurs the more likely long term symptoms Interesting Insights from John Briere Anxiety is the most probable residual symptom of trauma Current experience my trigger fear related to earlier trauma The current fear often makes no sense in the current situation Childhood trauma may have more to do with neglect abandonment or rejection than with actual abuse Interesting Insights from John Briere Depression may be more typical than anxiety in childhood trauma and in adult trauma related to natural disaster Helplessness hopelessness and low self esteem in the face of trauma may be cognitive distortions Often such distortions are preverbal and do not respond to talk therapyquot Only repetitive positive experience seems to be effective in changing these distortions to some degree Interesting Insights from John Briere Childhood trauma Predisposes to adult trauma Increases the effects of adult trauma Increases the likelihood of avoidant response Decreases positive prognosis There are adult trauma that can establish severe dysregulation without childhood trauma Confounds PTSD depression substance misuse and sexual dysfunction are all linked to victimization There is a legitimate question about whether these are separate or interrelated disorders 7 PTSD and depression snare common features loss of interest sleep disturbance diffculty concentrating 7 Loss ofsexual interest is a common feature of depression sexual ayoidance is a symptom of PTSD 7 Substance misusing indiyiduals who are yictims of abuse may also naye genetic loading forsubs ance misuse 7 Substance misuse can worsen depression and sexual dysfunction Confounds There is no research that looks at the sequencing of these disorders over the lifespan of victims and at their gradient of effect and perceived association Additionally there is little discussion of possible third variable explanations of the coincidence of these problems Consequences of Victimization amp Substance Use lnereased H ealtn Problems lnereased M ental Healtn Problems lncreased Substance UseAbuseSubstancer Related problems lnereased Barriers to Care substance Use Abuse lnereased Rlsky Sexual Elenayior lnereased Rlsk of Reyimimization Challenges Treatment of PTSD with Substance Use Disorder poses special challenges Lisa Najavitz of Harvard Medical School has developed and tested a presentcentered symptomfocused treatment for such cases It is a manualbased treatment consisting of 25 sessions Najavlts LlVl Weiss RD Shaw SR uenz L Seeking Safetv Outcome of a new cogn tlveabehav oral psvchotherapv tor Women With posttraumatc stress disorder and substance dependence JTraumatic Stress 1998 11437456 Longer term approaches after detox and immediate risk have dressed been ad Seeking Safety Lisa Nalavll addresses PTSD an VlCtlleathl l together it l5 an integrated treatmel l a roach u u OH Clinicians can select themes and topics and use Whateverorder theywant from the manual it also places emphasis on letting clients discoverwnatworks best for them e l39lol39ladll39ectlve but guided practice it emphasizes rehearsing coping skills and putting a clear focus at the beginning and end ofevery session it also strongly encourages 2 step participation wwwseekingsafetyorg It is based on the following principles 7 1 as the overarching goal helping clients attain safety in their relationships thinking behav or and substance abuse at the same tim e 3 Afocus on ideals to counteract the loss of deals in both PTSD and substance abuse 7 4 Four content areas cognitive behavioral interpersonal case management a 5 Attention m clinician processes helping clinicians work on countertransference selfacare and other issues a 2 Integrated treatment working on both PTSD and e Najavits LM 2002 Seeking Safety A Treatment Manual for PTSD and Substance Abuse New York NY Guilford Press Seeking Safety Goals The overall goal is to help clients be safe including Managing trauma symptoms Coping with life without substances Taking good care ofself Finding safe people to support clients Freeing from domestic violence Preventing selfdestructive acts Finding ways to feel good about self Group or individual With SEEKING SAFETY it doesn t matter either will work it was designed with group work in mind but could be used in individual sessions This approach structures sessions but without rigid boundaries Complete safety plans should be an integral part of sessions and clinicians should check in on how well clients are remaining aware of their plans and have fallbacks in place Seeking Safety The themes a selection 7 F39TSD Taking back yuur puvver 7 Detaching frurn ernutiunal pain 7 When substances cuntrul yuu 7 Asking furhelp 7 Taking guud care ufyuurself 7 Healing frurn anger Seeking Safety Protocol Sets bounda hour calls et Urinal is required in spite offeeling like re victimization toward clients it actually conveys seriousness of focus 7 Presented maner7er7raetiy ries at the beginning about after c 7 my mmermen enerp Contact with other clients outside of group Active followup on dro t Speci c discussion oftrauma histo reserved for individual sessions an ofthe ee ing Safety39 protocol per se In fact trauma histories are NOT assessed in are are outside great e ail Seeking Safety Session Format Basic structure of sessions 7 lntruductiun h Sessiunquutaliun 7 Sessiun tupi Tupi related in clients lives 39 Clients luuktnruugn nanduutstu get idea Sale cupingsnee cheekum Seeking Safety Session Format Each session begins with a checkin a brief review of what has happened that includes How are you feeling What good coping have you clone Any substance use or other unsafe behaviors Did you complete your commitment Community resource update Seeking Safety Session Format Sessions end with the checkout Name one thing you got out of today s session and any problems with the session What is your new commitment What community Resources will you call Self Esteem Model Miller and Downs developed a model related to loss of self esteem Victims experience selfderogation when the emotional impact of abuse overwhelms coping abilities leading to depression Substance misuse is an attempt to dampen selfdevaluation and decrease feelings of depression SelfBlame Model JannoffBulman and Thomas posit that victims experience characterological selfblame as opposed to behavioral selfblame resulting in loss of selfesteem and depression Substance misuse is an attempt to dampen self bame and depress39on This approach accords well with the guilty feelings often expressed by innocent victims Two Minute Paper Take one ortwo minutes to think and jot down an answer to the following question It is relatively easy to understand why abused children do not leave their parents but what factors prevent abused spouses from leaving their abusers Discuss your thoughts with a partner and be ready to share them with the class Subordination and Defeat When organisms are con 39onted by con ict with a dominant individuals they can ght ee or submit 7 Submission can lead to i eraffiliatioi i as a subordinate When all these options are thwarted the result is a defeated and depressed state In this model depression is the result ofan involuntary defeat strategyquot in which the individual annot win ee or af liate Sluman L amp Gilbert P 2UUUSubur1inatiun and defeat Ari evulununary approach El muud dimmers and theirtherapy NV Lawrence Eanbaum Assn cnn ict I d f accept W ugh Sgt yeasleaze i e em in submit Inn 53 l gm mined Invuluntary suburdmate meshed 39 Selfrpercepuun arrested defeated depressmn urEwLE new e 11 1 EE g w 1 7 3 339 L J 2 E aquot quot I um4w camsan mm Overall conceptual model 2 ii 225 E E 53 39n E M 5 E 2 3 9 m mm cumExmAL Loam mm em 5 Fhavens Lemae d 2nns Physical Assault 8 men 25 women v lctlmlzatlon Sexual Assault 43 to 55 of abused women Mental Health gt Substanee Use psychological Assault Threats centre 2 degmdatlon lsolatlon control Mental Health Problems d ff Substance Use Moo A ectlye Disord ers l related chsordecs H sh frequency of substanceuse and ngh equency of orbld Coem Vm mlzahon ln cornblnatlon dlsorders anxtety W 0th dlso erSWl emotlonal depress onlmoo i Mental Health 4 gt Suhstaaee Use P 1 5 dlsorders l Thlslncludes personallty mlsuse of alcohol dlsorders lllegal and substance use Wth mood dlsorders anxle prescnptlon drugs General Categories of Abuse R Uh Experiences n757 VSthuloglml some Same Maca Stalker Sexual Assam Lugan e Walker mus Health Status Differences Among Rural and Urban Women with and without Drug Abuse n757 Mental Health Status Differences Among Rural and Urban Women with and without Drug Abuse 57 Duration ofSIeep Among Women with Protective Orders and ational General Population ofWomenl sunmsmiess Over m 75 Hnurs EHnulsnrmnm HVIElIm Stuw m 757 lCzncer Prev smw 1n mm5 Walker Shannan Lugan zuua MW 6mm WNW Kim a mm m Percent of Women Reporting Past 30 Day Substance Use by Sleep Groups n757 I Rx aenznmzzenme 252 u Rx onmes rm lt5Hnursln 21m 5 Hnursm gt7Hnursm 2m 3139 W W WW Walker hannunlugan 2mm Women Reporting Prescription Opiate Use since Baseline 12 Months n 96 mm my my Lewis No Vam n m Moderate Vamln 35 Sea Vam in 5D pltm71 A conceptual model for understanding contributing factors and consequences of victimization Instead of thinking in terms of cooccurring disorders it s betterto think of Contributing factors situations disorders conditions that create vulnerabilities to victimization Consequences of victimization that result in situations disorders and conditions that then Contributing factors 20 Victimization Manifestations amp Vulnerabil victimization Physmzlzrd Mmmm o Mmmm 39 Substance Use smss Biological Vulnenbdmes andsubslance ms Physical and Mental Health Manifestations The experience of abuse is a high level stress that tends to be chronic the event may be re experienced in dreams ashbacks and intrusive memories women once victimized may be revictimized violence perpetrated by an intimate partner tends to be repeated lt distorts the normal stress response by creating a heightened state of alarm which has serious consequences HPA Axis mm m I Q a 21 HPA Cascade an Axis Response 1 us Nylllllhlllmux I L a run in ry a an mm m l Biological Vulnerability and Traumatlc stress may result lrl changes lrl bralrl structures neuruchemistry and stress hormone function e llessacllyalesmehypemalamlcpllullalyaulenalalls HPA axis 7 There ls evidencelhal especiallylraumali abuse el pelslslem sllessllem living in abusNe silualiuns may cause mule pelmanem changes lnme HPAaxis and W012 brain slem and diencephalun Wamen mu chlldhaad hislmies m abuse and eunem depressan has 5x elealel ACYH advenammcmmpic humane vespanse than men Wm rm abuse manly abnamially meu levels m wally lawlevels m eemal While ueplesslen havelhe DPPDsile 39WamethPYSD have navepinephvine and alarm Warner Wm Biological Vulnerability and Abnormal levels of cortisol and norepinephrine can contribute to and prolong PTSD depression and anxiety In addition to increasing likelihood of mental health and substance abuse problems these factors can impair response to danger cues leading to increased likelihood of revictimization Biological Vulnerability and Changes Increased levels of cortisol impair both long and short term memory by reducing cell volume in the hippocampus This effects Storage of new information Retrieval ofdeclarative memory oflife events Substance use also effects memory process Biological Vulnerability and hanges In addition to increasing the likelihood of emotional problems disturbance ofthe HPA axis contributes to physical illness Impairment in immune response Fibromyalgia and chronic pain conditions Disorders of the coronary and circulatory sys em A range of GI disorders IBS Biological Vulnerability and hanges Changes is the organization ofthe brain can cause or contribute to multiple problems 5HT mediated functions can be disturbed leading to depressionanxiety Depression increases sensitivity to and experience of pain Disturbed sleep may increase incidence of coronary problems mortality and mental health problems 23 Biological Vulnerability and Changes The whole range of physical and emotional problems creates unique vulnerability to substance misuse Anxiety depression sleep disturbance chronic pain general life dissatisfaction individually and in combination are powerful reasons to misuse substances Substance misuse can create the illusion of relief while ultimately worsening the condition Mental Health Manifestations Although the exact relationship between victimization and mental health problems is not fully understood it is clearthat women with histories of victimization have a much higher incidence of various mental health problems than women without such a histor Depression Anxiety disorders and PTSD Borderline Personality Disorder There may also be some possible link between victimization and eating disorders Genetic Vulnerabilities Some individuals may be more genetically predisposed to anxiety or depression They require far less stress to initiate problems Further they may be also more prone to respond positively to the effect of substances Some individuals may be genetically predisposed to various physical problems as a result of stress 24 Genetic Vulnerabilities Certain inherited character traits like harm avoidance or hperarousability may make it difficult for some individuals to take assertive action in the face of abuse Of course some individuals are genetically predisposed to develop dependence on substances of various kinds Victimization Manifestations amp Vulnerabilities Lifestyle Factors I Assunauuns mmth t Riskyercepuuns v ictimization Lifestyle Factors These are behaviors that result from free choices however this does not imply that women choose to be victimized Many choices are made incautiously Other choices are influenced by one s culture Still other choices lea to chains of unforeseen causality 25 Associations He who fears the wolf should not go into the forestquot Russian Prwerb a woman associates with are more likely to be perpetrators she is more like yto end up a victim nvironments are more likely to have a high density of potential perpetrators than at er Some activities like substance use are more likley to ring a person in contact with individuals who are opportunistic pre a ors Certainly exchange of sex for drugs money or other necessities is more likely to expose a women to victimization Others Perception of Vulnerability Substance use tends to increase the perception by potential predators of a woman as vulnerable Further women involved in illegal behavior are generally more reluctant to report assault and therefore perceived as more vulnerable Women alone in places where there are no Witnesses can also be perceived as more vulnerable Perhapsthe most striking example of combined assomation and perceived vulnerability are homeless women Risk Perception This is a women s own perception of her own risk forvictimization Substance use is the single most salient factor affecting risk perception Women may als perceive less risk from potential predators with whom they have some casual acquaintance Also alter mental state as in mood or anxiety disorder limits accurate risk perception 26 Lifestyle Factors I Assunauuns Vulna39abxhly Risk Percepuuns unnecunumlc talus Victimization Facaved Opuuns quot Mental Health gt Substance Use Sunal Envimnmem Vic mization Manifestations amp Vulnerabilit39es mowed apes Socioeconomic Status Although more affluent women are not immune from intimate violence careful epidemiologic research indicates that lower socioeconomic women report more incidents of partner violence Being poor is inherently more stressful than being affluent If you are poor you are more likley to live in areas with high rates of violent crime Social Environment Behaviors are developmental SLT would predict that individuals from violent families of origin would be likely to establish violent families because of learned values role definitions problem solving styles and understanding of what is acceptable behavior Similarly individuals from substance misusing families of origin would be more likely to misuse substances for very similar reasons strongly influenced by the environment 27 Social Environment As Bruce Perry points out individuals whose brains were organized in neglectful chaotic or abuse environments are quite Iikley to have significant problems moderating their own responses and more likely to become perpetrators or victims than individuals without such a history Social and cultural norms are difficult when associated with specific ethnicity or culture Social Environment However it is easier to understand that males socialized to see heavy use of alcohol as normative and violence as an acceptable way to resolve con ict would be more likely to be abusive This is especially true if they socialize only with other males who have similar beliefs or if they are socially kewise women who believe that their role is to be subservient and that occasional violence is just part ofa relationship would be more li e yto be victimized Finally community norms my proscribe reporting of intimate violence to authorities Social Environment Amartia Sen pointed out that poverty is not essentially a lack ofmoney it is a lack of access to resources W are poor or who are isolated may not perceive that they have any options except to remain in violent relationships any communities women not only perceive they have few options they actually do have few options In poor neighborhoods or rural areas individuals social r s may be quite small an 0 not have better information about options than in individual herself 28 Victimization Manifestations amp Lifestyle Factors I Associations Vulna39ability Risk Percepuuns omen viiinembiiiues N Victimization o pigmimi a m antxl Health 11 2 thl39estn mis g E 8 quot a quota Emlugml 5 vmnembiiiues and Substance gt Use situaan Remunse Apmel 31 A p ccimuve Constraints Internal Contextual Factors Internal Contextual Factors These involve the internal representation system that a person has about herself the world in general social relations in particular and the expected ordering of these factors Unlike otherfactors it is internal and may not be observable but only inferred from behavior Situation Appraisal The basic notion here is that appraisal of the nature of a situation will give rise to emotions and eventual behavior in relation to that situation The same situation may be appraised by one individual as threatening give rise to fear and ovo e avoi ance orinadequate performance by another as an opportunity give rise to feelin s of con dence and anticipation and provoke positive performance and satisfaction The same event may be viewed as neutral by one person and terrifying by another the question is why 29 Situation Appraisal Internal and External Standards Is the situation fair normal and congruent with personal goals motives and co do With how the individual expects to be treated ll l a Specific Situatio yiewed studies orwomen wno n s xually assauited met legal criteria forrape oniy 49 to 62 defined tneir experieri e as r pe 4 u di not report to p el no narm was intended 65 felt it was not serious enougn to report Situation Appraisal Is the situation compatible with the perceived norms or demands of an important reference group in terms of desirability or expected cond This is largely a cultural matter how does the culture de ne intimate viol nce and what is expected in a relation 39 The culture may be a large community or ethnic group or a family culture Situation Appraisal Memory It is possible that women with suppressed memories of past victim experiences may not be good at recognizing present danger cu Certainiy substance use and depression can interfere witn awareness omen witn ayoidant copi to ayoid stimuiated rep Women witn nypeiyigiiance may naye tneir focus narrowed by ai ixiety and not recognize dangercues tnat are different from past experieric rig styies may ignore present cues ressed memories 30 Situation Appraisal Cognitive Biases Overly optimistic bias may cause a women to ignore negative factors in the social environment and be more susceptible to victimization Just World bias may cause a women to believe that only good things happen to good people and bad things happen to only bad people Situation Appraisal Personal Goals This is largely a self in relationshi model that posits that women tend to define themselves and their life goals in terms of relationships more than do men This may cause women to blame themselves or the relationship forviolence ratherthan the perpetrator or see their role as one of changing or saving the perpetrator Situation Appraisal Sense of Agency This has to do with how much a person feels in control of her life capable of makin choices and willing to accept responsibility and consequences Individuals who have external locus of control see themselves as helpless or are fatalistic are less likely to avoid violent relationships or extricate themselves Situation Appraisal Sense of Agency There is also the factor of selfregulation This has to do with the ability ofan individual to regulate both internal states and external Individuals with poor selfregulation may feel rwhelmed b internal negative selftalk and may end up feeling quite depressed worthless and guilty Such a state can lead to substance use which is no better regulated than internal negative states Response Appraisal This has to do with how a woman assesses various responses to a violent relationship If a woman blames herself or the relationship for the violence the way she assesses her response will be quite different from that of a woman who blames her perpetrator Multiple experiences of victimization may be more likely to lead to selfblame Response Appraisal Self blame Can be behavioral selfblame which is associated with one s behavior and therefore more controllable and modifiable Can be characterological selfblame which is related to some aspect of self and assumed to be less controllable and changeable 32 Response Appraisal Anticipated Outcomes Women do a kind ofcostbene t analysis ofpossible responses to intimate violence Ifthe cost is thoughtto be less then the bene t than actions is likely to be taken Ifthe cost is greater than the bene t than action is unlikely Much ofthe analysis is based on what the woman knows or suspects about the response ofvarious organizations like the police courts protective services Response Appraisal Some of the possible costs could involve greaterviolence not being taken seriously by the authorities exposure to shame a ridicule loss of income potential Ios f custody of children loss of domicile rejection by family death The potential benefits of a violence free life may seem quite hypothetical in the face of the looming costs unless adequate support is available Cognitive Constraints In a neighborhood and coping with any number of s ressors Ability to cope is largely determined by the internal resources of a erson her coping skil s and strategies her ability to organize and take effective action Likewise ability to cope is largely determined by external resources in ofsocial networks of family 39iends social institutions and organizations 33 Cognitive Constraints High levels of stress caused by marital discord job dissatisfaction poverty social isolation dwindling social system resources emotional problems substance use poor health etc may overwhelm a persons ability to accurately appraise danger and take effective action Cognitive Constraints Additionally multiple victimizations may sap internal resources and cause women to be more socially isolated This phenomenon has been clearly linked to increased incidence ofmental health and substance use problems Additionally it is linked to greater likelihood of medical lems Finally it creates the greater likelihood ofselfblame and loss of selfef cacy Cognitive Constraints All ofthe above make it more difficult for women to make appropriate appraisal of their risks It also makes it more difficult forthem to take action even if they are aware of risk It is the larger context in which situation appraisal and response appraisal happen 34 Clinical Implications The picture forvictims of intimate violence is extremely complex and addressing it requires a willingness to explore a broad range of factor that all contribute to the problem Clinicians need to learn how to expire the broad range of factors that may be at work in individual case and use this knowledge to guide treatment planning and treatment delivery Even after safety has been established the victim is far from well Sexual Dysfunction There are consistent findings linking sexual abuse in childhood to sexual dysfunction in adulthood This finding is specific to women primarily due to the higher prevalence of sexual abuse of females Sexual dysfunction seems linked with depression and substance misuse in these women The Grossest Clinical Implications What is clear is that clients presenting for substance use problems should assessed for victimization depression PTSD and sexual dysfunction Likewise victims of abuse should be assessed for substance misuse as well as PTSD depression and sexual dysfunction 35 The Grossest Clinical Implications When comorbid conditions are identified in an individual treatment should be designed to simultaneously address the complex of problems rather than only one At our current state of knowledge this seems the most effective although not easiest way to proceed 36